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Wednesday, September 1, 2010
At The Home of Real Fitba
TO Bellsdale Park, home of Beith Juniors, for the first round draw for the Scottish Cup and to find the Beith committee-members present unsure whether to laugh or cry.
Their club last played in the "big" Scottish Cup in 1937, when they were walloped 4-0 at Love Street by St Mirren. Winning the Stagecoach West of Scotland Superleague last season got them another crack at the big prize.
"Firstly, I want a home draw", said Beith boss Johnny Miller. Well the wee man got his wish when former St Mirren boss Gus MacPherson pulled their name out of the glass bowl.
But ex-Celt Tommy Coyne, who was drawing the away teams, didn't do so well for Beith, when he paired the North Ayrshire side with Emirates Scottish Junior Cup holders Linlithgow Rose.
"At least, it guarantees one junior team in the second round and we have home advantage, but, it will be a hard match", said Miller.
With so many glorified pub teams from the lesser "senior" leagues in the first round, draw it's a shame that two of the bigger names were paired together, but junior fans will be confident that Bo'ness United, the East Superleague champions, can see off Selkirk when they venture into the heart of rugby country on 25 September.
Now, I have never had any prior dealings with SFA George Peat and it is to my shame that I have perhaps been influenced by the thinking of fellow scribes, who have dealings with him. I thought him a stumbling block to progress, the last of the discredited old guard - then I spent five minutes or so with him and discovered: he is NOT against change in Scottish football; he would WELCOME the introduction of the pyramid some of us have been seeking for years and he wants to see the more progressive clubs from outwith the top 42 getting a chance to progress.
Great.
However, he did point out that there is a lot of indifference about change among the junior ranks, where clubs are happier guddling about in the midden they've inhabited for years and fearful of what change and attempting to better themselves might bring.
That's typically Scots. It has always been thus.
As the lairds and clan chiefs cleared the Highlands, the more-ambitious sailed off to colonise Canada, advance Australia fair, put fresh zeal into New Zealand and subjugate large tracts of sub-Saharan Africa.
The moderately-ambitious went south to make Glasgow the Second City of the Empire or headed into England where one Scot arriving in even the most mundane medium-sized town would immediately double the average IQ.
The rest, they stayed at home and became subsidy junkies.
Same in football - the great early English teams were choc-a-bloc with Scots, a trend which has only passed in recent years, as the sons of the rest became what's available.
Maybe there's something to be said for taking Scots out of Scotland; something in the water here apparently holds us back.
Nursing Care Plan | NCP Hypernatremia
Hypernatremia is a condition in which the serum sodium concentration is greater than 145 mEq/L (normal range is 136 to 145 mEq/L). Sodium is the most abundant cation in the body; a 70-kg person has approximately 4200 mEq of sodium. About 30% of the total body sodium, called silent sodium, is bound with bone and other tissues; the remaining 70%, called the exchangeable sodium, is dissolved in the extracellular fluid (ECF) compartment or in the compartments in communication with the ECF compartment. Sodium has five essential functions: It maintains the osmolarity of the ECF; it maintains ECF volume and water distribution; it affects the concentration, excretion, and absorption of other electrolytes, particularly potassium and chloride; it combines with other ions to maintain acid-base balance; and it is essential for impulse transmission of nerve and muscle fibers.
Hypernatremia is a fairly rare electrolyte imbalance that occurs in less than 1% of all hospital admissions and is unusual in patients who are awake, are alert, and have an intact thirst response. When it does occur, mortality may be as high as 50%. Hypernatremia usually occurs when there is an excess of sodium in relation to water in the ECF compartment, resulting in hyperosmolarity of the ECF, which produces a shift in water from the cells to the ECF. The result is cellular dehydration. Three different manifestations of hypernatremia have been described, based on the ratio of total body water (TBW) to total body sodium: hypovolemic hypernatremia,
hypervolemic hypernatremia, and euvolemic hypernatremia. The cause of hypernatremia is associated with the ratio of TBW to total body sodium. In hypernatremia, there is often an excess of sodium relative to TBW.
Nursing care plan assessment and physical examination
Inquire about the patient’s daily fluid and salt intake. Patients with hypernatremia often report a decrease in fluid intake and possibly a high salt intake. Since polyuria moving to oliguria is an early sign of hypernatremia, ask about daily urine output and if the urine appears concentrated. Question the patient about fever, diarrhea, and vomiting, which might contribute to dehydration. If hypernatremia is severe, the patient may be confused. Ask the family if the patient has been lethargic, disoriented, or agitated. These changes in mental status, along with occurrence of a seizure, indicate severe hypernatremia.
Assess the patient’s vital signs; fever, tachycardia, decreased blood pressure, and orthostatic hypotension are characteristic of hypernatremia. Assess the skin and mucous membranes for signs of dehydration. With pronounced hypernatremia, expect poor skin turgor; flushed skin color; dry mucous membranes; and a rough, dry tongue. With more severe hypernatremia, assess the patient for muscle twitching, hyperreflexia, tremors, seizures, and rigid paralysis.
Assess the patient’s ability to obtain adequate fluid intake. The patient’s lethargic state contributes to the poor fluid intake. Assess the quality and support of the caregivers regarding their ability to provide for the patient’s fluid intake. Since in severe hypernatremia, the symptoms are primarily neurological, assess the patient’s level of orientation and her or his ability to communicate needs. Assess the safety needs of the patient, especially for the disoriented elderly or debilitated patient. Note that central nervous system symptoms are particularly upsetting for the patient and family and may create anxiety over the patient’s long-term prognosis.
Nursing care plan primary nursing diagnosis: Fluid volume deficit related to fluid loss, inadequate fluid intake, or fluid shifts to the extravascular space.
Nursing care plan intervention and treatment plan
The goal is to decrease the total body sodium and replace the fluid loss. Encourage liquids; if the patient cannot tolerate fluids, an intravenous (IV) hypotonic electrolyte solution (0.2% or 0.45% sodium chloride) or salt-free solution is usually ordered. Sometimes these two types of solutions are alternated to prevent hyponatremia. If 5% dextrose in water is ordered, monitor the urine output because this solution encourages diuresis, which can aggravate the hypernatremic condition. Maintain intake and output records and weigh the patient each day to monitor the fluid volume status.
Monitor the patient’s serum sodium levels daily as well to determine the effectiveness of IV fluids. Administer the water replacement slowly as prescribed to reduce the serum sodium levels not more than 2 mEq/L per hour. If hypernatremia is corrected too quickly, the ECF shifts into the cells, resulting in cerebral edema and neurological problems. Monitor the patient for signs and symptoms of cerebral edema: headache, lethargy, nausea, vomiting, widening pulse pressure, and decreased pulse rate. Sometimes, diuretic therapy is indicated to increase sodium excretion, along with a decrease of oral sodium intake in the diet. No pharmacologic management is usually required other than IV therapy. Independent
Offer fluids and water frequently to patients with hypernatremia. Avoid caffeinated fluids and alcohol because they can increase the serum sodium level by causing water diuresis. Notify the physician of any changes in mental status, such as agitation, confusion, and disorientation. If the patient is at risk for seizures, initiate seizure precautions.
Give oral care every 2 hours; avoid using lemon glycerin swabs and alcoholic mouthwashes because they have a drying effect and can cause discomfort. Monitor the condition of the skin, and assist with position changes frequently. Determine the patient’s ability to ambulate safely. If the patient is confused and disoriented, maintain the bed in the lowest position and maintain safety measures.
Nursing care plan discharge and home health care guidelines
Teach the patient and his or her caregivers the importance of an adequate fluid intake and normal sodium intake. Discuss the foods that are appropriate for a low-sodium diet, if indicated. Advise the patient or significant others to avoid over-the-counter medications that are high in sodium. Teach the patient about the early signs of hypernatremia: polyuria, nausea, vomiting, and orthostatic hypotension. Explain that as hypernatremia becomes severe, the patient or family will note changes in the patient’s mental status. Encourage the patient or significant others to notify the primary healthcare provider if any of these signs and symptoms occur.
Hypernatremia is a fairly rare electrolyte imbalance that occurs in less than 1% of all hospital admissions and is unusual in patients who are awake, are alert, and have an intact thirst response. When it does occur, mortality may be as high as 50%. Hypernatremia usually occurs when there is an excess of sodium in relation to water in the ECF compartment, resulting in hyperosmolarity of the ECF, which produces a shift in water from the cells to the ECF. The result is cellular dehydration. Three different manifestations of hypernatremia have been described, based on the ratio of total body water (TBW) to total body sodium: hypovolemic hypernatremia,
hypervolemic hypernatremia, and euvolemic hypernatremia. The cause of hypernatremia is associated with the ratio of TBW to total body sodium. In hypernatremia, there is often an excess of sodium relative to TBW.
Nursing care plan assessment and physical examination
Inquire about the patient’s daily fluid and salt intake. Patients with hypernatremia often report a decrease in fluid intake and possibly a high salt intake. Since polyuria moving to oliguria is an early sign of hypernatremia, ask about daily urine output and if the urine appears concentrated. Question the patient about fever, diarrhea, and vomiting, which might contribute to dehydration. If hypernatremia is severe, the patient may be confused. Ask the family if the patient has been lethargic, disoriented, or agitated. These changes in mental status, along with occurrence of a seizure, indicate severe hypernatremia.
Assess the patient’s vital signs; fever, tachycardia, decreased blood pressure, and orthostatic hypotension are characteristic of hypernatremia. Assess the skin and mucous membranes for signs of dehydration. With pronounced hypernatremia, expect poor skin turgor; flushed skin color; dry mucous membranes; and a rough, dry tongue. With more severe hypernatremia, assess the patient for muscle twitching, hyperreflexia, tremors, seizures, and rigid paralysis.
Assess the patient’s ability to obtain adequate fluid intake. The patient’s lethargic state contributes to the poor fluid intake. Assess the quality and support of the caregivers regarding their ability to provide for the patient’s fluid intake. Since in severe hypernatremia, the symptoms are primarily neurological, assess the patient’s level of orientation and her or his ability to communicate needs. Assess the safety needs of the patient, especially for the disoriented elderly or debilitated patient. Note that central nervous system symptoms are particularly upsetting for the patient and family and may create anxiety over the patient’s long-term prognosis.
Nursing care plan primary nursing diagnosis: Fluid volume deficit related to fluid loss, inadequate fluid intake, or fluid shifts to the extravascular space.
Nursing care plan intervention and treatment plan
The goal is to decrease the total body sodium and replace the fluid loss. Encourage liquids; if the patient cannot tolerate fluids, an intravenous (IV) hypotonic electrolyte solution (0.2% or 0.45% sodium chloride) or salt-free solution is usually ordered. Sometimes these two types of solutions are alternated to prevent hyponatremia. If 5% dextrose in water is ordered, monitor the urine output because this solution encourages diuresis, which can aggravate the hypernatremic condition. Maintain intake and output records and weigh the patient each day to monitor the fluid volume status.
Monitor the patient’s serum sodium levels daily as well to determine the effectiveness of IV fluids. Administer the water replacement slowly as prescribed to reduce the serum sodium levels not more than 2 mEq/L per hour. If hypernatremia is corrected too quickly, the ECF shifts into the cells, resulting in cerebral edema and neurological problems. Monitor the patient for signs and symptoms of cerebral edema: headache, lethargy, nausea, vomiting, widening pulse pressure, and decreased pulse rate. Sometimes, diuretic therapy is indicated to increase sodium excretion, along with a decrease of oral sodium intake in the diet. No pharmacologic management is usually required other than IV therapy. Independent
Offer fluids and water frequently to patients with hypernatremia. Avoid caffeinated fluids and alcohol because they can increase the serum sodium level by causing water diuresis. Notify the physician of any changes in mental status, such as agitation, confusion, and disorientation. If the patient is at risk for seizures, initiate seizure precautions.
Give oral care every 2 hours; avoid using lemon glycerin swabs and alcoholic mouthwashes because they have a drying effect and can cause discomfort. Monitor the condition of the skin, and assist with position changes frequently. Determine the patient’s ability to ambulate safely. If the patient is confused and disoriented, maintain the bed in the lowest position and maintain safety measures.
Nursing care plan discharge and home health care guidelines
Teach the patient and his or her caregivers the importance of an adequate fluid intake and normal sodium intake. Discuss the foods that are appropriate for a low-sodium diet, if indicated. Advise the patient or significant others to avoid over-the-counter medications that are high in sodium. Teach the patient about the early signs of hypernatremia: polyuria, nausea, vomiting, and orthostatic hypotension. Explain that as hypernatremia becomes severe, the patient or family will note changes in the patient’s mental status. Encourage the patient or significant others to notify the primary healthcare provider if any of these signs and symptoms occur.
Nursing Care Plan | NCP Hypermagnesemia
Hypermagnesemia occurs when the serum magnesium concentration is greater than 2.7 mg/dL (2.3 mEq/L), but signs and symptoms do not occur until the magnesium reaches 4 mg/dL. The normal serum magnesium level is 1.7 to 2.7 mg/dL (1.4 to 2.3 mEq/L). Magnesium is found in the bones: 1% is located in the extracellular compartment, and the remainder is found within the cells.
Magnesium plays an important role in neuromuscular function. It also has a role in several enzyme systems, particularly the metabolism of carbohydrates and proteins, as well as maintenance of normal ionic balance (it triggers the sodium-potassium pump), osmotic pressure, myocardial functioning, and bone metabolism. Because the kidneys are able to excrete large amounts of magnesium ( 5000 mg/day), either the patient has to ingest extraordinary amounts of magnesium or the glomerular filtration of the kidneys needs to be very depressed for the patient to develop hypermagnesemia. Complications include complete heart block, cardiac arrest, and respiratory paralysis.
Hypermagnesemia, although rare, usually occurs in patients with chronic renal disease who consume excessive quantities of magnesium, commonly in the form of magnesium-containing laxatives or antacids. Obstetric patients who are treated with parenteral magnesium for preeclampsia or patients with acute adrenocortical insufficiency (Addison’s disease) may also develop hypermagnesemia. Both hypothermia and shock can also lead to a high serum magnesium level.
Nursing care plan assessment and physical examination
The patient’s chief complaint may be muscle weakness and fatigue. Precipitating factors may include renal failure, laxative or antacid abuse, adrenal insufficiency, diabetes, or acidosis. Medication history may include magnesium-containing laxatives such as milk of magnesia, antacids that contain magnesium hydroxide, or parenteral administration of magnesium sulfate. Ask the patient to describe any symptoms, which may range from none to full cardiopulmonary arrest. The patient may experience nausea and vomiting, flushed skin, or diaphoresis; changes in the cardiac rhythm lead to palpitations or dizziness, depression, lethargy, thirst, muscle weakness, or even paralysis.
Generally, patients do not develop signs and symptoms until the serum magnesium reaches more than 4 mEq/L. Assess the vital signs, which may show tachycardia, bradycardia, or hypotension. The patient may be disoriented, confused, or even unresponsive. When strength and movement are assessed, you may find the patient has lost deep tendon reflexes, has muscle weakness, and may even have some paralysis. Cardiopulmonary arrest may occur when the respiratory muscles are paralyzed as a result of a magnesium level in excess of 10 mEq/L or as a consequence of depressed myocardial contractility.
The patient with hypermagnesemia usually has chronic renal failure. Assess the patient’s ability to cope with a chronic disease, as well as an acute complication. The patient may have had to cope with a change in lifestyle and roles that may be compromised by the sudden and potentially life-threatening complication of hypermagnesemia. The patient’s degree of anxiety about the illness should also be assessed.
Nursing care plan primary nursing diagnosis: Risk for injury related to neurosensory alterations secondary to hypermagnesemia.
Nursing care plan intervention and treatment plan
The physician discontinues all medications that contain magnesium. The patient may be given calcium gluconate in emergencies to antagonize the effects of magnesium. If the patient does not have severe renal failure, 1000 mL of 0.9% saline with 2 g of calcium gluconate may be infused to increase magnesium excretion at a rate of 150 to 200 mL per hour. In patients with inadequate renal function, the physician may prescribe dialysis with magnesium-free dialysate. Prompt supportive therapy is essential, such as mechanical ventilation if the patient has respiratory failure or a temporary pacemaker if the patient has symptomatic bradycardia.
During treatment, monitor the serum magnesium in patients at risk for hypermagnesemia. Monitor vital signs, urine output, and the neuromuscular status, including level of consciousness, orientation, and muscle strength and function. Assess the patellar (knee-jerk) reflex in patients with a magnesium level above 5 mEq/L:With the patient lying flat or sitting on the side of the bed, support the knee and tap the patellar tendon firmly just below the patella. A normal response is extension of the knee. An absent reflex may indicate a magnesium level greater than
7 mEq/L and should be reported to the physician.
Maintain the patient’s airway, breathing, and circulation until the magnesium levels return to normal. Have emergency airway equipment and a manual resuscitator bag at the patient’s bedside at all times. Keep a working endotracheal suction present. Maintain patient safety measures. Reassure the patient and significant others that the patient’s neuromuscular status will return to baseline with treatment.
Educate the patient with chronic renal failure to review all over-the-counter medications with the physician and pharmacist before use. These medications include vitamin supplements that contain minerals because these usually contain magnesium. Provide a list of common magnesiumcontaining medications that the patient should avoid.
Nursing care plan discharge and home health care guidelines
To prevent a recurrence of hypermagnesemia, teach the patient to avoid sources of magnesium such as laxatives, antacids, and vitamin-mineral supplements and to consult with the pharmacist or physician before using any over-the-counter medications. The patient should also be taught the signs and symptoms of hypermagnesemia (changes in level of consciousness, neuromuscular weakness, nausea and vomiting) and instructed to notify the physician if these return.
If the patient suffered from prolonged neuromuscular symptoms, he or she may have developed muscle weakness as a result of disease. Teach safety measures to the patient and significant others, including the use of any assistive devices (cane or walker) and seeking assistance when ambulating. The patient should also be taught muscle-strengthening exercises and may need a home care evaluation before being discharged.
Magnesium plays an important role in neuromuscular function. It also has a role in several enzyme systems, particularly the metabolism of carbohydrates and proteins, as well as maintenance of normal ionic balance (it triggers the sodium-potassium pump), osmotic pressure, myocardial functioning, and bone metabolism. Because the kidneys are able to excrete large amounts of magnesium ( 5000 mg/day), either the patient has to ingest extraordinary amounts of magnesium or the glomerular filtration of the kidneys needs to be very depressed for the patient to develop hypermagnesemia. Complications include complete heart block, cardiac arrest, and respiratory paralysis.
Hypermagnesemia, although rare, usually occurs in patients with chronic renal disease who consume excessive quantities of magnesium, commonly in the form of magnesium-containing laxatives or antacids. Obstetric patients who are treated with parenteral magnesium for preeclampsia or patients with acute adrenocortical insufficiency (Addison’s disease) may also develop hypermagnesemia. Both hypothermia and shock can also lead to a high serum magnesium level.
Nursing care plan assessment and physical examination
The patient’s chief complaint may be muscle weakness and fatigue. Precipitating factors may include renal failure, laxative or antacid abuse, adrenal insufficiency, diabetes, or acidosis. Medication history may include magnesium-containing laxatives such as milk of magnesia, antacids that contain magnesium hydroxide, or parenteral administration of magnesium sulfate. Ask the patient to describe any symptoms, which may range from none to full cardiopulmonary arrest. The patient may experience nausea and vomiting, flushed skin, or diaphoresis; changes in the cardiac rhythm lead to palpitations or dizziness, depression, lethargy, thirst, muscle weakness, or even paralysis.
Generally, patients do not develop signs and symptoms until the serum magnesium reaches more than 4 mEq/L. Assess the vital signs, which may show tachycardia, bradycardia, or hypotension. The patient may be disoriented, confused, or even unresponsive. When strength and movement are assessed, you may find the patient has lost deep tendon reflexes, has muscle weakness, and may even have some paralysis. Cardiopulmonary arrest may occur when the respiratory muscles are paralyzed as a result of a magnesium level in excess of 10 mEq/L or as a consequence of depressed myocardial contractility.
The patient with hypermagnesemia usually has chronic renal failure. Assess the patient’s ability to cope with a chronic disease, as well as an acute complication. The patient may have had to cope with a change in lifestyle and roles that may be compromised by the sudden and potentially life-threatening complication of hypermagnesemia. The patient’s degree of anxiety about the illness should also be assessed.
Nursing care plan primary nursing diagnosis: Risk for injury related to neurosensory alterations secondary to hypermagnesemia.
Nursing care plan intervention and treatment plan
The physician discontinues all medications that contain magnesium. The patient may be given calcium gluconate in emergencies to antagonize the effects of magnesium. If the patient does not have severe renal failure, 1000 mL of 0.9% saline with 2 g of calcium gluconate may be infused to increase magnesium excretion at a rate of 150 to 200 mL per hour. In patients with inadequate renal function, the physician may prescribe dialysis with magnesium-free dialysate. Prompt supportive therapy is essential, such as mechanical ventilation if the patient has respiratory failure or a temporary pacemaker if the patient has symptomatic bradycardia.
During treatment, monitor the serum magnesium in patients at risk for hypermagnesemia. Monitor vital signs, urine output, and the neuromuscular status, including level of consciousness, orientation, and muscle strength and function. Assess the patellar (knee-jerk) reflex in patients with a magnesium level above 5 mEq/L:With the patient lying flat or sitting on the side of the bed, support the knee and tap the patellar tendon firmly just below the patella. A normal response is extension of the knee. An absent reflex may indicate a magnesium level greater than
7 mEq/L and should be reported to the physician.
Maintain the patient’s airway, breathing, and circulation until the magnesium levels return to normal. Have emergency airway equipment and a manual resuscitator bag at the patient’s bedside at all times. Keep a working endotracheal suction present. Maintain patient safety measures. Reassure the patient and significant others that the patient’s neuromuscular status will return to baseline with treatment.
Educate the patient with chronic renal failure to review all over-the-counter medications with the physician and pharmacist before use. These medications include vitamin supplements that contain minerals because these usually contain magnesium. Provide a list of common magnesiumcontaining medications that the patient should avoid.
Nursing care plan discharge and home health care guidelines
To prevent a recurrence of hypermagnesemia, teach the patient to avoid sources of magnesium such as laxatives, antacids, and vitamin-mineral supplements and to consult with the pharmacist or physician before using any over-the-counter medications. The patient should also be taught the signs and symptoms of hypermagnesemia (changes in level of consciousness, neuromuscular weakness, nausea and vomiting) and instructed to notify the physician if these return.
If the patient suffered from prolonged neuromuscular symptoms, he or she may have developed muscle weakness as a result of disease. Teach safety measures to the patient and significant others, including the use of any assistive devices (cane or walker) and seeking assistance when ambulating. The patient should also be taught muscle-strengthening exercises and may need a home care evaluation before being discharged.
Nursing Care Plan | NCP Hyperlipoproteinemia
Hyperlipoproteinemia is a condition of increased lipids (fats) in the blood that has been caused by an increased rate of synthesis or a decreased rate of lipoprotein breakdown. Because lipoproteins transport triglycerides and cholesterol in the plasma, an increased level may cause pancreatitis and atherosclerosis.
Lipids are a mixed group of biochemical substances that are manufactured by the body or are derived from metabolism of ingested substances. The plasma lipids (cholesterols, triglycerides, phospholipids, and free fatty acids) are derived from dietary sources and lipid synthesis. Cholesterol and triglycerides are implicated in atherogenesis.
Hyperlipidemia, an elevation of serum cholesterol or triglycerides, can be primary or secondary to another underlying condition. Lipoprotein elevation, or hyperlipoproteinemia, is described by five specific types: types I, II, III, IV, and V
Primary hyperlipoproteinemia results from rare genetic disorders. Secondary hyperlipoproteinemia occurs as a manifestation of other diseases, which include hypothyroidism, nephrotic syndrome, diabetes mellitus, alcoholism, glycogen storage disease (type I), Cushing’s syndrome, acromegaly, anorexia, renal disease, liver diseases, immunologic disorders, stress, and the use of oral contraceptives or glucocorticoids.
Nursing care plan assessment and physical examination
Take a thorough history of existing illnesses because secondary hyperlipoproteinemia is related to a number of other conditions. Ask the patient if he or she has a history of renal or liver disease, diabetes mellitus, other endocrine diseases, or immune disorders. Ask if the patient is taking corticosteroids or oral contraceptives, and determine the extent of the patient’s alcohol use. Because hyperlipoproteinemia is sometimes treated with a range of bile acid sequestrant medications, which can affect the absorption of other medications, ask if the patient is taking any of the following: warfarin, thiazides, thyroxine, beta-adrenergic blockers, fat-soluble vitamins, folic acid, diuretics, or digitoxin. Symptoms of hyperlipoproteinemia vary, depending on which of the five types the patient has. Ask about recurrent bouts of severe abdominal pain, usually preceded by fat intake, or if the patient has experienced malaise, anorexia, or fever.
Observe general appearance for signs of obesity, which may be an exacerbating factor for hyperlipoproteinemia. Inspection may reveal papular or eruptive deposits of fat (xanthomas) over pressure points and extensor surfaces; likely locations include the Achilles’ tendons, hand and foot tendons, elbows, knees, and hands and fingertips (where you may observe orange or yellow discolorations of the palmar and digital creases). Ophthalmoscopic examination typically reveals reddish-white retinal vessels. In some forms of hyperlipoproteinemia, an opaque ring surrounding the corneal periphery (juvenile corneal arcus) is visible. Palpate the abdomen for spasm, rigidity, rebound tenderness, liver or spleen tenderness, and hepatosplenomegaly. Check for signs of hypertension and hyperuricemia.
Hyperlipoproteinemia is not an abrupt illness; it develops over years. The patient may have developed coping mechanisms during that time, but the patient may be anxious because of accelerated symptoms of atherosclerosis and CAD. The patient may have experienced the premature death of parents from this disorder and have long-lasting fears about her or his own early death. Body image disturbance may also occur because of obesity or the presence of unsightly xanthomas.
Nursing care plan primary nursing diagnosis: Altered nutrition: More than body requirements related to lipoprotein accumulation and accelerated blockage of the coronary arteries.
Nursing care plan intervention and treatment plan
The primary treatment is dietary management, weight reduction, increased physical activity, and the restriction of saturated animal fat and cholesterol intake. Adding polyunsaturated vegetable oils to the diet helps reduce LDL-C concentration. Secondary treatment is aimed at reducing or eliminating aggravating factors, such as alcoholism, diabetes mellitus, or hypothyroidism. To reduce risk factors that contribute to atherosclerosis, the regimen includes treating hypertension, implementing an exercise program, controlling blood sugar, and stopping smoking. For type V hyperlipoproteinemia, female patients are taken off oral contraceptives. Medications may also be prescribed to lower the plasma concentration of lipoproteins, either by decreasing their production or by increasing their removal from plasma.
In rare instances, for patients who cannot tolerate medication therapy, surgical creation of an ileal bypass may be necessary to accelerate the loss of bile acids in the stool and lower plasma cholesterol levels. For children with severe disease, surgery to create a portacaval shunt may be performed as a last resort to decrease plasma cholesterol levels. Plasma exchanges may also be used to reduce cholesterol levels.
Teach the patient about ways to manage diet to control the disorder. Urge the patient to adhere to a 1000- to 1500-calorie per day diet and avoid excess sugar intake. Explain the components of the lipid profile and their ramifications and discuss various means of lowering very low density lipoprotein (VLDL) and LDL levels and increasing high-density lipoprotein (HDL) levels.
Explain the prescribed medication regimen, by providing verbal and written information to the patient or significant others. Refer to effective programs or support groups for controlling cigarette and alcohol use. Teach alternate methods of contraception to the female patient who can no longer use oral contraceptives. A patient faces significant health threats unless he or she makes permanent lifestyle changes. Encourage him or her to verbalize fears, such as those concerning CAD. Offer support and provide clear explanations for the patient’s questions about the lifestyle changes and consequences.
Nursing care plan discharge and home health care guidelines
Teach the patient the importance of dietary and lifestyle changes. Refer the patient to a dietician if appropriate. Be sure the patient understands all medications, including the dosage, route,
action, adverse effects, and the need for routine laboratory monitoring for lipid profiles.
Teach the patient to report to her or his physician the occurrence of signs and symptoms of CAD, such as chest pain, shortness of breath, and changes in mental status. Teach the patient the need for follow-up serum cholesterol and serum triglyceride tests. Instruct the patient to maintain a stable body weight and to adhere to any dietary restrictions before undergoing cholesterol tests. Most tests require the patient to fast for 12 hours before the test.
Lipids are a mixed group of biochemical substances that are manufactured by the body or are derived from metabolism of ingested substances. The plasma lipids (cholesterols, triglycerides, phospholipids, and free fatty acids) are derived from dietary sources and lipid synthesis. Cholesterol and triglycerides are implicated in atherogenesis.
Hyperlipidemia, an elevation of serum cholesterol or triglycerides, can be primary or secondary to another underlying condition. Lipoprotein elevation, or hyperlipoproteinemia, is described by five specific types: types I, II, III, IV, and V
Primary hyperlipoproteinemia results from rare genetic disorders. Secondary hyperlipoproteinemia occurs as a manifestation of other diseases, which include hypothyroidism, nephrotic syndrome, diabetes mellitus, alcoholism, glycogen storage disease (type I), Cushing’s syndrome, acromegaly, anorexia, renal disease, liver diseases, immunologic disorders, stress, and the use of oral contraceptives or glucocorticoids.
Nursing care plan assessment and physical examination
Take a thorough history of existing illnesses because secondary hyperlipoproteinemia is related to a number of other conditions. Ask the patient if he or she has a history of renal or liver disease, diabetes mellitus, other endocrine diseases, or immune disorders. Ask if the patient is taking corticosteroids or oral contraceptives, and determine the extent of the patient’s alcohol use. Because hyperlipoproteinemia is sometimes treated with a range of bile acid sequestrant medications, which can affect the absorption of other medications, ask if the patient is taking any of the following: warfarin, thiazides, thyroxine, beta-adrenergic blockers, fat-soluble vitamins, folic acid, diuretics, or digitoxin. Symptoms of hyperlipoproteinemia vary, depending on which of the five types the patient has. Ask about recurrent bouts of severe abdominal pain, usually preceded by fat intake, or if the patient has experienced malaise, anorexia, or fever.
Observe general appearance for signs of obesity, which may be an exacerbating factor for hyperlipoproteinemia. Inspection may reveal papular or eruptive deposits of fat (xanthomas) over pressure points and extensor surfaces; likely locations include the Achilles’ tendons, hand and foot tendons, elbows, knees, and hands and fingertips (where you may observe orange or yellow discolorations of the palmar and digital creases). Ophthalmoscopic examination typically reveals reddish-white retinal vessels. In some forms of hyperlipoproteinemia, an opaque ring surrounding the corneal periphery (juvenile corneal arcus) is visible. Palpate the abdomen for spasm, rigidity, rebound tenderness, liver or spleen tenderness, and hepatosplenomegaly. Check for signs of hypertension and hyperuricemia.
Hyperlipoproteinemia is not an abrupt illness; it develops over years. The patient may have developed coping mechanisms during that time, but the patient may be anxious because of accelerated symptoms of atherosclerosis and CAD. The patient may have experienced the premature death of parents from this disorder and have long-lasting fears about her or his own early death. Body image disturbance may also occur because of obesity or the presence of unsightly xanthomas.
Nursing care plan primary nursing diagnosis: Altered nutrition: More than body requirements related to lipoprotein accumulation and accelerated blockage of the coronary arteries.
Nursing care plan intervention and treatment plan
The primary treatment is dietary management, weight reduction, increased physical activity, and the restriction of saturated animal fat and cholesterol intake. Adding polyunsaturated vegetable oils to the diet helps reduce LDL-C concentration. Secondary treatment is aimed at reducing or eliminating aggravating factors, such as alcoholism, diabetes mellitus, or hypothyroidism. To reduce risk factors that contribute to atherosclerosis, the regimen includes treating hypertension, implementing an exercise program, controlling blood sugar, and stopping smoking. For type V hyperlipoproteinemia, female patients are taken off oral contraceptives. Medications may also be prescribed to lower the plasma concentration of lipoproteins, either by decreasing their production or by increasing their removal from plasma.
In rare instances, for patients who cannot tolerate medication therapy, surgical creation of an ileal bypass may be necessary to accelerate the loss of bile acids in the stool and lower plasma cholesterol levels. For children with severe disease, surgery to create a portacaval shunt may be performed as a last resort to decrease plasma cholesterol levels. Plasma exchanges may also be used to reduce cholesterol levels.
Teach the patient about ways to manage diet to control the disorder. Urge the patient to adhere to a 1000- to 1500-calorie per day diet and avoid excess sugar intake. Explain the components of the lipid profile and their ramifications and discuss various means of lowering very low density lipoprotein (VLDL) and LDL levels and increasing high-density lipoprotein (HDL) levels.
Explain the prescribed medication regimen, by providing verbal and written information to the patient or significant others. Refer to effective programs or support groups for controlling cigarette and alcohol use. Teach alternate methods of contraception to the female patient who can no longer use oral contraceptives. A patient faces significant health threats unless he or she makes permanent lifestyle changes. Encourage him or her to verbalize fears, such as those concerning CAD. Offer support and provide clear explanations for the patient’s questions about the lifestyle changes and consequences.
Nursing care plan discharge and home health care guidelines
Teach the patient the importance of dietary and lifestyle changes. Refer the patient to a dietician if appropriate. Be sure the patient understands all medications, including the dosage, route,
action, adverse effects, and the need for routine laboratory monitoring for lipid profiles.
Teach the patient to report to her or his physician the occurrence of signs and symptoms of CAD, such as chest pain, shortness of breath, and changes in mental status. Teach the patient the need for follow-up serum cholesterol and serum triglyceride tests. Instruct the patient to maintain a stable body weight and to adhere to any dietary restrictions before undergoing cholesterol tests. Most tests require the patient to fast for 12 hours before the test.
Nursing Care Plan | NCP Gallbladder and Biliary Duct (Biliary System) Cancer
Gallbladder cancer and biliary duct cancer are relatively rare and account for fewer than 1% of all cancers. In 2005, over 3200 cases will be diagnosed and almost 2000 people will die of this cancer. Gallbladder cancer occurs five times more often in Native Americans than in whites and is more common in white females than in African American females. Most cancers of the gallbladder and biliary tract are inoperable at the time of diagnosis. If the cancer has been found incidentally at the time of a cholecystectomy, longer survival may be possible. More than 75% of gallbladder cancers are nonpapillary adenocarcinomas and approximately 6% are papillary adenocarcinomas; a small number are squamous cell, adenosquamous cell, mucinous, or small cell carcinomas. Papillary cancers have a better prognosis and grow along the connective tissue and blood vessels; they are not as likely to metastasize to the liver and lymph nodes. Adenocarcinomas occur most frequently at the bifurcation in the common bile duct.
Biliary system cancer is insidious and metastasizes via the lymphatic and blood systems and by direct extension to the liver, pancreas, stomach, and duodenum. Invasion of the gastrointestinal (GI) tract can cause complete obstruction of the extrahepatic bile ducts with intrahepatic biliary dilation and enlargement of the liver. If the tumor is restricted to one hepatic duct, biliary obstruction is incomplete and jaundice may not be present. Inflammatory disorders such as cholangitis (bile duct inflammation) and peritonitis often obscure an underlying malignancy. Infection often accompanies cancer of the gallbladder, and bile duct cancers are associated with ulcerative colitis. In most patients with gallbladder and biliary cancer, the disease progresses rapidly and patients usually survive little more than a year after diagnosis.
The cause of biliary system cancer is unknown, although a possibility is gallstones. When gallstones are present, bile is released more slowly. If the bile contains carcinogens, the gallbladder tissue is exposed to these carcinogens for a longer period of time. Approximately 1% of all cholecystectomy specimens are found to be cancerous. Because of the risk of cancer, even for asymptomatic cholelithiasis, a cholecystectomy is recommended. Primary carcinoma of the gallbladder is rare and is usually associated with cholecystitis. Most biliary cancer is from metastasis, commonly from the head of the pancreas.
Nursing care plan assessment and physical examination
Some patients who do not have symptoms that can be traced back to the gallbladder may describe symptoms similar to those of cholelithiasis or cholecystitis because these result from obstruction and inflammation of the biliary tree. The most common symptom is intermittent to steady pain in the upper right abdomen. Mild pain in the epigastric area may also be reported. GI symptoms are related to the blockage of bile. Patients may complain of anorexia, nausea, vomiting, belching, diarrhea, and weight loss. Diarrhea may be related to steatorrhea, and weight loss can be as much as 14 to 28 pounds. Because of frequent metastasis to the liver and pancreas, there may be clinical manifestations of cancer in those organs.
Patients with extensive disease may appear thin and malnourished. Determine if the patient is jaundiced from an enlarging tumor that is pressing on the extrahepatic ducts, but note that jaundice may be delayed if only one main duct is involved. Inspect for skin irritation and skin trauma because of pruritus. If the tumor is of sufficient size, an abdominal mass may be palpated; this mass in the gallbladder area feels hard and is sometimes tender. Intrahepatic metastases are not usually palpable. If the abdomen is distended, individual organs may be difficult to palpate. The liver may be very large and smooth, 5 to 12 cm below the costal margin.
Because the prognosis of biliary cancer is poor, determine how much the patient understands. Determine if the patient is moving through the stages of death and dying, and be accepting of the patient’s attitude toward the diagnosis.
Nursing care plan primary nursing diagnosis: Pain (acute) related to obstruction of biliary tree.
Nursing care plan intervention and treatment plan
Most medical treatment is aimed at supportive care, such as controlling the GI symptoms and the discomforts of jaundice. A cholecystectomy is done as soon as possible after the cancer is detected, although the cancer may have been found by doing the surgery for cholecystitis. Surgery may include removal of a section of the liver. Internal radiotherapy, using iridium-129 wire or radium needles, may be combined with biliary drainage. Chemotherapy has not been shown to be effective against this cancer. External radiation may be used palliatively for cancer of the bile duct but is not effective against gallbladder cancer. If the tumor is inoperable or increases in size after surgery and is occluding any of the bile ducts, palliative measures may be taken to allow the bile to flow into the duodenum. Drainage of the bile can be accomplished by an external system, similar to that of a T-tube, or an internal stent that drains directly into the duodenum. As an alternative to surgery, a stent made of specialized plastic or steel is placed either by endoscopy or percutaneously through the tumor to allow drainage of the trapped bile. Complications include cholangitis and obstruction and dislocation of the stent.
Dietary changes are similar to those needed by patients with cholelithiasis, except the emphasis is on gaining weight rather than on weight reduction. A diet balanced with high calories and protein and low fat helps control the GI symptoms. Each individual needs to determine what foods are best tolerated. Medications to control nausea may be needed before meals, and the patient usually needs a pain-control regimen.
The nurse has an important role in maximizing the patient’s comfort. To augment the pain control obtained from analgesia, initiate nonpharmacologic strategies. Allow the patient to participate in the activities of daily living as much as possible. Assist with personal hygiene as much as needed, and include the significant others in learning the process. The itching associated with pruritus can be controlled by maintaining skin integrity, using soft, dry linens and cloths and warm water for bathing. Keep the area around all surgical incisions and drainage devices clean and dry. A large number of support groups exist to help patients and families manage cancer. Listen to the patient’s concerns. Give the patient and family the number for the American Cancer Society and hospice care if appropriate.
Nursing care plan discharge and home health care guidelines
Whether the tube is internal or external, teach the patient the signs and symptoms of a blocked tube. If the drainage system is external, teach the patient how to care for the tube, including emptying of the bag, irrigating the tube, periodic clamping of the tube, and managing skin care around the tube. Teach the patient to report signs of infection, excessive drainage, leakage, and obstruction to the physician. Provide the patient with a contact phone number. Teach the patient methods to control itching. Teach the patient about each medication, including the purpose and correct dosages, along with any potential side effects. Explain the requirements for a low-fat, high-calorie, and high-protein diet.
Biliary system cancer is insidious and metastasizes via the lymphatic and blood systems and by direct extension to the liver, pancreas, stomach, and duodenum. Invasion of the gastrointestinal (GI) tract can cause complete obstruction of the extrahepatic bile ducts with intrahepatic biliary dilation and enlargement of the liver. If the tumor is restricted to one hepatic duct, biliary obstruction is incomplete and jaundice may not be present. Inflammatory disorders such as cholangitis (bile duct inflammation) and peritonitis often obscure an underlying malignancy. Infection often accompanies cancer of the gallbladder, and bile duct cancers are associated with ulcerative colitis. In most patients with gallbladder and biliary cancer, the disease progresses rapidly and patients usually survive little more than a year after diagnosis.
The cause of biliary system cancer is unknown, although a possibility is gallstones. When gallstones are present, bile is released more slowly. If the bile contains carcinogens, the gallbladder tissue is exposed to these carcinogens for a longer period of time. Approximately 1% of all cholecystectomy specimens are found to be cancerous. Because of the risk of cancer, even for asymptomatic cholelithiasis, a cholecystectomy is recommended. Primary carcinoma of the gallbladder is rare and is usually associated with cholecystitis. Most biliary cancer is from metastasis, commonly from the head of the pancreas.
Nursing care plan assessment and physical examination
Some patients who do not have symptoms that can be traced back to the gallbladder may describe symptoms similar to those of cholelithiasis or cholecystitis because these result from obstruction and inflammation of the biliary tree. The most common symptom is intermittent to steady pain in the upper right abdomen. Mild pain in the epigastric area may also be reported. GI symptoms are related to the blockage of bile. Patients may complain of anorexia, nausea, vomiting, belching, diarrhea, and weight loss. Diarrhea may be related to steatorrhea, and weight loss can be as much as 14 to 28 pounds. Because of frequent metastasis to the liver and pancreas, there may be clinical manifestations of cancer in those organs.
Patients with extensive disease may appear thin and malnourished. Determine if the patient is jaundiced from an enlarging tumor that is pressing on the extrahepatic ducts, but note that jaundice may be delayed if only one main duct is involved. Inspect for skin irritation and skin trauma because of pruritus. If the tumor is of sufficient size, an abdominal mass may be palpated; this mass in the gallbladder area feels hard and is sometimes tender. Intrahepatic metastases are not usually palpable. If the abdomen is distended, individual organs may be difficult to palpate. The liver may be very large and smooth, 5 to 12 cm below the costal margin.
Because the prognosis of biliary cancer is poor, determine how much the patient understands. Determine if the patient is moving through the stages of death and dying, and be accepting of the patient’s attitude toward the diagnosis.
Nursing care plan primary nursing diagnosis: Pain (acute) related to obstruction of biliary tree.
Nursing care plan intervention and treatment plan
Most medical treatment is aimed at supportive care, such as controlling the GI symptoms and the discomforts of jaundice. A cholecystectomy is done as soon as possible after the cancer is detected, although the cancer may have been found by doing the surgery for cholecystitis. Surgery may include removal of a section of the liver. Internal radiotherapy, using iridium-129 wire or radium needles, may be combined with biliary drainage. Chemotherapy has not been shown to be effective against this cancer. External radiation may be used palliatively for cancer of the bile duct but is not effective against gallbladder cancer. If the tumor is inoperable or increases in size after surgery and is occluding any of the bile ducts, palliative measures may be taken to allow the bile to flow into the duodenum. Drainage of the bile can be accomplished by an external system, similar to that of a T-tube, or an internal stent that drains directly into the duodenum. As an alternative to surgery, a stent made of specialized plastic or steel is placed either by endoscopy or percutaneously through the tumor to allow drainage of the trapped bile. Complications include cholangitis and obstruction and dislocation of the stent.
Dietary changes are similar to those needed by patients with cholelithiasis, except the emphasis is on gaining weight rather than on weight reduction. A diet balanced with high calories and protein and low fat helps control the GI symptoms. Each individual needs to determine what foods are best tolerated. Medications to control nausea may be needed before meals, and the patient usually needs a pain-control regimen.
The nurse has an important role in maximizing the patient’s comfort. To augment the pain control obtained from analgesia, initiate nonpharmacologic strategies. Allow the patient to participate in the activities of daily living as much as possible. Assist with personal hygiene as much as needed, and include the significant others in learning the process. The itching associated with pruritus can be controlled by maintaining skin integrity, using soft, dry linens and cloths and warm water for bathing. Keep the area around all surgical incisions and drainage devices clean and dry. A large number of support groups exist to help patients and families manage cancer. Listen to the patient’s concerns. Give the patient and family the number for the American Cancer Society and hospice care if appropriate.
Nursing care plan discharge and home health care guidelines
Whether the tube is internal or external, teach the patient the signs and symptoms of a blocked tube. If the drainage system is external, teach the patient how to care for the tube, including emptying of the bag, irrigating the tube, periodic clamping of the tube, and managing skin care around the tube. Teach the patient to report signs of infection, excessive drainage, leakage, and obstruction to the physician. Provide the patient with a contact phone number. Teach the patient methods to control itching. Teach the patient about each medication, including the purpose and correct dosages, along with any potential side effects. Explain the requirements for a low-fat, high-calorie, and high-protein diet.
Top MBA Programs in Ireland
List of top MBA programs offered by business schools in Ireland:
University of Dublin (Trinity College Dublin) - The Trinity MBA was one of the first MBA programs in Europe, and is situated within one of the oldest universities in the world. In 1999 it became the first Irish program to receive international accreditation from the International Association of MBAs (AMBA). Trinity's Business
University of Dublin (Trinity College Dublin) - The Trinity MBA was one of the first MBA programs in Europe, and is situated within one of the oldest universities in the world. In 1999 it became the first Irish program to receive international accreditation from the International Association of MBAs (AMBA). Trinity's Business
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